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Currents Feb. 3

To Medical Center Employees:
At the Feb. 10 management communications meeting Pat Votava, manager of Medically Fragile Children’s Program and co-team leader of the MUSC Excellence Communication Team, announced plans for a “You Make a Difference” e-mail to all medical center employees to recognize individuals’ exceptional performance. The plan is to identify outstanding care and service through comments included in the Patient Satisfaction (Press Ganey) reports. The Press Ganey super users will provide the communication team with this information.

You Make a Difference recognition will begin with plain text e-mails, but the communication team plans for these e-mails to evolve into graphically designed and colorful e-mails with photos.
We are continuing to work hard on controlling costs while ensuring for high quality and compassionate care. I will be speaking to our financial situation in greater detail during a series of town hall meetings scheduled for March. The schedule including times and locations is listed below. Additional town hall meetings are being scheduled for some large departments.
We know that many hospitals have observed decreasing patient satisfaction results as staff morale has been affected by cost containment initiatives or other organizational change. Our patient satisfaction scores have remained strong in a number of areas, but we have some work to do in other areas. Following is a summary of patient satisfaction results for the current quarter through Feb. 10.

Patient Satisfaction Results
Jan. 1 – Feb. 10
Service                                    Percentile               Mean
Adult Hospitals                        61 (N 426)                85.9
Pediatric Inpatient                    91 (N 80)                  88.7
Pediatric Emergency Room      77 (N 72)                  87.1
Ambulatory Care                     78 (N 1745)              91.5
Outpatient Behavioral Health    83 (N 208)                92.3

While not indicated above, the Digestive Diseases inpatient area scored the 79th percentile and Heart and Vascular inpatient area ranked the 94th percentile. In the near future we expect to routinely report patient satisfaction results by service line in this newsletter.

Thank you very much.

W. Stuart Smith
Vice President for Clinical Operations
and Executive Director, MUSC Medical Center

People—Fostering employee pride and loyalty

 Linda Formby, R.N., manager for Infection Prevention and Control, and Cassandra Salgado, M.D., hospital epidemiologist, praised managers for reducing infection rates in 2008 compared with 2007 standards within specific hospital units, thus having made a positive impact on hospital finances, patient satisfaction and patient mortality. Formby reminded staff that staff infection preventionists within the department consistently use the Centers for Disease Control and Prevention’s definitions for health care-associated infections and consistently apply them across the enterprise. Salgado noted that specific criteria were utilized to determine which units were eligible for recognition.
Formby and Salgado presented certificates of excellence to unit/department team nurse managers and infection control preventionists (IP): Pediatric ICUs (monitor reductions in ventilator-associated pneumonia (VAP) infection rates and central line associated blood stream infection rates (CLABSI): NNICU—Kathie Chase, nurse manager, and Wanda Beardsley, (IP); PICU— Melinda Biller, nurse manager and Beth Rhoton, IP; PCU—Kim Montgomery, nurse manager, and Rhoton, IP; Respiratory Therapy (reduction in VAP)– Marian Miller; 7CHB (reduction in CLABSI)—Karen Ingram, nurse manager and Rhoton IP; Adult ICUs (monitor reductions in VAP, CLABSI, Methicillin-resistant staphylococcus aureus (MRSA) and/or Vancomycin-resistant enterococcus (VRE)); 4STICU—Tom Hubbard, former nurse manager and Pam Fogle, IP; 8NSI—Cheryl Holderfield, nurse manager and Mary Allen, IP; MICU—Janet Byrne, nurse manager and Wanda Beardsley, IP; 4CT/4CCU—Bob Anthony, nurse manager and Bernadette Garry, IP; Adult Respiratory Therapy (reduction in VAP)—Jo Anne Sandefur, manager and Donna Bolus, manager, MICU/8NSI/4STICU. Adult Floor Unit—6W (reductions in MRSA and VRE)—Kari O’Coin, nurse manager and Pam Fogle, IP.

You Make a Difference Program
Pat Votava, manager of Medically Fragile Children’s Program and co-chair of MUSC Excellence Communications Team, gave an update by the team. The communications team includes co-chair Alex Sargeant, Mary Stoll, Linda Randazzo, Laurie Zone-Smith, Ph.D., R.N., Maggie Thompson, Stephanie Davis, Michael Irving and Hope Colyer.
The team will communicate new information about new initiatives, remind staff about “must haves” and promote new tools. Votava reminded managers that the communications team’s mission is to move information to line staff in order to provide the best care on a daily basis. Starting Feb. 12, the team will share a new tool with MUSC employees called “You Make a Difference,” a mass e-mail from Stuart Smith that highlights a story submitted by a patient/patient family about an employee who demonstrates excellence through attitude and service. The story also will connect to the employee’s department and progress with their Press Ganey scores.

Service—Serving the public with compassion, respect and excellence
Melissa Feather, R.N., manager for Meducare, was available to answer any questions from managers and staff regarding MUSC’s Patient/Family Shuttle operations. Feather reported that ridership remains high. A report showed that more than 800 riders used the shuttle in December. Jan. 4 was the first day MUSC employees/staff rode the shuttle.

Quality—Providing quality patient care in a safe environment
Karen Rankine, R.N., manager of education and training for MUHA Human Resources and member of the Joint Commission Interdis-ciplinary Survey Readiness Rounds team, discussed details relating to the review of personnel files.
Using the same format for rounding, Rankine reviewed things that have worked positively. Rankine feels there has been an increased knowledge of documentation requirements with units/department’s file to comply with the Joint Commission Human Resources (HR) Standards. Rankine reminded managers that the HR standards have not changed much. With increase knowledge is an increase in compliance for docu-mentation requirements in the file. MUSC’s goal is to provide 100 percent compliance.
Areas that need improvement include:

  • Orientation documentation is not complete or not in file—competency based orientation, unit/department orientation and charge nurse competency based orientation
  • Required certification is not in file or has expired—serious offense

Tools and resources available:

  • Personnel File Review Guide is on the MUHA HR Web site
  • Personnel File Review training sessions are held monthly—Next session is Feb. 12, ART Auditorium (offered alternatively between the main hospital and ART). Register via CATTS.
  • Individual training is also available with managers, administrative assistants or educators
  • Personnel file set up (organization) is on the MUHA HR Web site
  • Unit/Department Orientation template for non-clinical employees can be found on the MUHA intranet Web site. For information, call 792-7690.

The next meeting is Feb. 17.

Organizers have started beta testing in MUHA departments with six liaisons already trained and five plans in progress. Hematology/Oncology was the first department to complete their plan.
Next steps include: Identification/verification of departmental/unit plans are needed; identification of departmental/unit Business Continuity liaisons; and completion of surveys and development of uniform BCPs.
Target completion date is April 30.

Standard of Behavior—February
Meredith Strehle, marketing and service excellence manager for Children’s and Perinatal Services and co-chair of the MUHA Excellence Standards Team, reviewed February’s best practice and standard of behavior—keep all interactions positive and discuss internal issues with those who only need to know. The team is introducing a best practice of applying the key word “excellence” as a peer-to-peer, positive cue to all employees to follow the standards of behavior in the workplace. Look for examples of proper use/application of the code word in future e-mails and the communications Web site.

HR update

  • N-95 Respirator Fit Testing for February and March—The mass fit testing is open to students and employees who use this item. An OSHA Respirator Medical Evaluation Questionnaire for fit testing must be completed and signed off by a registered nurse. Any staff who answers yes  must go to Employee Health Services for an evaluation. Dates are Feb. 9 and 23, 11 a.m. to 4 p.m.; and March 9 and 23, 11 a.m. to 4 p.m. All at 2W Amphitheater.
  • MUHA’s Tuition Assistance Policy #17 had some modifications to the policy as of October 2008.

Eligible employees must complete Section A: The employee must be considered by the Authority to be in a regular, permanent position and have successfully completed the one year probationary period.
Section B—Modified maximum tuition assistance to $5,250 per fiscal year. Note: The modification of maximum amount applies to requests for tuition assistance course work received for approval after Oct. 6, 2008. However, the change from calendar year to fiscal year was effective Oct. 6, 2008.)
Service Commitment is calculated based on one month of full-time employment for each $400 tuition assistance received.
IWR report is available. The report will be modified by Feb. 7-8 to include payback amount. (Managers should contact MUHA HR for final payback amount). Employee must sign a promissory note and is responsible for service commitment or repayment.
Benefit of the Month—February
Mark Stimpson, benefits manager, shared details regarding the change between Aetna and Prudential for long-term care insurance or nursing home care insurance. It provides financial help for someone dealing with a debilitating illness or injury that is unable to perform daily living activities.
Care may be provided at home or at a licensed facility by a professional or informal caregiver (friend or relative). Long-term care insurance supports patients with spinal cord injuries, Parkinson’s, Alzheimer’s or stroke recovery patient.
MUHA HR will offer an open enrollment period to employees from Feb. 16 to March 6.
Employees who enroll during this time can avoid the need to prove good health. Coverage would begin on April 1 and is completely portable. Premiums are paid to Prudential and not payroll deduction.

Employees may apply for coverage for spouses, parents, grandparents and themselves at any time throughout 2009, but need to declare their past medical history. Prudential has the right to decline coverage based on this.  
To enroll, call (877) 214-6588 or visit
Additionally, a Prudential represent-ative will conduct informational sessions at the medical center: Feb. 18 , 11 a.m., SEI Auditorium and 1 p.m., Room 628, Clinical Sciences Building; and Feb. 24, 2 p.m. and 3 p.m., 2W Amphitheater.
For an appointment, call 792-9320.

Service—Serving the public with compassion, respect and excellence

Melissa Feather, Medu-care clinical manager, answered questions re-garding changes to the Patient and Family Shuttle. The service has expanded support to include MUSC staff as well as patients and families to ride a continuous, set route between McClennan Banks, Hollings Cancer Center, Clinical Sciences Building, Rutledge Tower  and Ashley River Tower. With three separate shuttles, all are on a rotating schedule.
Since it is a patient-centered service, the shuttle does not follow a set schedule. Wheel-chair patients, patients and their families will always be a priority with this service.

Quality—Providing quality  patient care in a safe environment

Mary Stoll, Environment of Care program, updated managers on the Joint Commission Interdisciplinary Survey Readiness Rounds. Stoll reviewed the topic of obstructions, especially in all corridors and with fire safety equipment. She reviewed photos of common obstructions throughout the medical center. Items such as beds, carts, Wallaroo workstations, wheelchairs, ladders, and other items can be found in corridors. The team reviewed needed changes with staff in order to stay compliant. Mayday carts are the only items that are allowed to be stored in hallways.
For bed surplus pick-up, call Environmental Services, 792-4571; For surplus items, fax PEA form to 876-7004 or call 876-7285/7000. For special situations, call Safety & Security, 792-6902. Other questions, call 792-5176.

Melissa Meara Martin, R.N., is the new procedural nurse manager of Hema-pheresis, Dialysis and Radiology Nursing. Management thanked Laurie Zone-Smith, Ph.D., R.N., Elizabeth Perry, R.N., Carol Corbin, R.N., Stephanie Severance, R.N. and Kathie Lubert, R.N., who helped cover these areas since last July.
The next meeting is Feb. 10.

Friday, Feb. 13, 2009

The Catalyst Online is published weekly by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. The Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, Editorial copy can be submitted to The Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to To place an ad in The Catalyst hardcopy, call Island Publications at 849-1778, ext. 201.